RN Clinical Documentation Improvement Specialist

EQUAL EMPLOYMENT OPPORTUNITY

Race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate shall not be a factor in employment for this position. Due to the nature of hospital services, it may become necessary to work extended hours. POSITION SUMMARY

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This onsite position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients, and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

POSITION SUPERVISORY RESPONSIBILITIES

Reports To:

Coding/CDI Manager, Health Information Management

Supervises:

None POSITION REQUIREMENTS

Minimum Education

Associates degree

Minimum Work Experience

Three (3) years or more experience in medical record data abstraction related to coding, quality monitoring, or clinical documentation improvement.

Required Licenses/Certifications

RN license

Required Skills, Knowledge, and Abilities

Excellent communication, interpersonal, collaboration and customer relations skills. Ability to analyze data for patterns and trends. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills. Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required

Preferred Qualification

CDIP, CCDS, RHIT or RHIA credentials PHYSICAL REQUIREMENTS

Primarily sedentary working reviewing records and keying information using a computer monitor and keyboard. Ability to concentrate and read for long periods of time. Quiet surrounding with adequate lighting

QUALITY BEHAVIORAL EXPECTATIONS

Generally and in all job specific duties: Uses critical thinking skills to determine evidence based solutions. Systematically gathers and reviews pertinent information to prevent errors (PDCA -- Plan, Do, Check, Act). Pursues individual or team learning and growth opportunities to continually build skills. Understands and abides by all safety regulations.

SERVICE EXCELLENCE BEHAVIORAL EXPECTATIONS

Generally and in all job specific duties: Maintains patient confidentiality. Rounds regularly with patients, direct reports and/or customers. Uses telephone and elevator etiquette. Acts as an employee ambassador. Committed to know hospital service lines and shows pride in our organization. Uses AIDET when dealing with internal or external customers. FISCAL RESPONSIBILITY BEHAVIORAL EXPECTATIONS

Generally and in all job specific duties: Takes responsibility for solving problems. Treats company resources responsibly. Performs work functions timely and accurately. Respects our environment; keeps public areas neat and clean and returns supplies to the appropriate areas.

PEOPLE BEHAVIORAL EXPECTATIONS

Generally and in all job specific duties: Supports the team through good attendance. Maintains a professional appearance. Creates a positive team environment; flexible and supportive setting an example of cooperation. Uses meaningful communication; provides honest feedback that is valuable and not critical and discourages negative talk and gossip. Respect co-workers.

JOB SPECIFIC FUNCTIONS

Demonstrates an understanding of and adherence to the HMHD Compliance Plan.

Conduct reflects HMHD's values and a commitment to HMHD's Code of Conduct.

Attends the required corporate integrity and compliance training and education programs.

Demonstrates proficiency in understanding the materials presented during the corporate integrity and compliance training and education program.

Complies with all HIPAA standards.

Performs initial medical record review, within 24-48 hours of admission, using documentation improvement guidelines to evaluate overall quality and completeness of clinical documentation.

Per review policies and procedures, conducts at least 2-3 follow-up reviews of clinical documentation prior to discharge to review any subsequent findings that have not been documented by the treating provider.

Assigns a working DRG using official coding rules and guidelines to determine severity of illness, risk of mortality, risk adjustment, HCCs, and length of stay. Be familiar with MS-DRG/APR-DRGs and Inpatient Prospective Payment system (IPPS).

Generate Recent Suggested Working DRG Report in Dolbey Fusion and forward to case managers daily.

Queries providers on a concurrent basis as needed to clarify documentation in the medical records using ACDIS and AHIMA compliant query practices.

Conducts post discharge reviews with HIM Coding staff when the working and final DRG do not match.

Collaborates with the HIM Coding staff and/or CDI 2nd Level Review Auditor to review accounts with PPCs, PSIs, mortality reviews, and coding denials to determine any post discharge queries needed to clarify the conditions documented in the medical records for quality outcomes.

Develops and conducts ongoing education for providers as well as new staff such as new CDI Specialists.

Participates on internal committees as requested by the HIM Department Director.

Maintains positive open communication with providers, case managers, coders, and other members of the care team as it relates to clinical documentation.

Assists with special projects as needed and performs related duties as assigned by the HIM Manager and Director.

The above statement reflect the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered as a detailed description of all of the work requirements inherent in the position.